Code Code Type Definition
80061 CPT® L– this panel must include the following: cholesterol, serum, total (82465); lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718); and triglycerides (84478)
80061 Lipid Panel
82465 Assay BLD/Serum Cholesterol
83718 Assay of Lipoprotein
84478 Assay of Triglycerides
HCPCS/CPT Codes/Diagnosis Codes
The following HCPCS/CPT Codes are to be billed for the Cardiovascular Screening Blood Tests:
• 80061 Lipid Panel
• 82465 Cholesterol, serum, or whole blood, total
• 83718 Lipoprotein, direct measurement; high-density cholesterol
• 84478 Triglycerides
(The tests should be performed as a panel; however, they are also available as individual tests.)
The following diagnosis codes must be submitted on the claim for when billing for cardiovascular screening blood test:
• V 81.0 Special Screening for ischemic heart disease
• V81.1 Special Screening for hypertension
• V81.2 Special Screening for other and unspecified cardiovascular conditions Medicare will pay for cardiovascular disease screening under the Medicare Clinical
Laboratory Fee Schedule. Providers and suppliers that bill for the cardiovascular disease screening benefit must point the screening diagnosis (V81.0, V81.1,
V81.2) to the line item service.
Other cardiovascular screening blood tests (for which CMS has not specifically indicated approval for national coverage) continue to be non-covered.
How Carriers and Intermediaries Will Treat Claims
Medicare carriers and intermediaries will treat claims as follows:
• Carriers/intermediaries will accept claims with HCPCS 80061 (Lipid Panel), 82465 (Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct
measurement; high density cholesterol, HDL Cholesterol), or 84478 (Triglycerides) when there is a reported diagnosis of V81.0 (Special screening for ischemic heart disease), V81.1 (Special screening for hypertension), or V81.2 (Special screening for other and unspecified cardiovascular conditions).
• Carriers/intermediaries will deny claims with code 80061 when there is already evidence of a paid claim within the prior 60 months that was billed with a
diagnosis code of V81.0, V81.1, or V81.2, and with a procedure code of 80061, 82465, 83718, or 84478.
• Carriers/intermediaries will deny claims with procedure codes of 82465, 83718, or 84478 when billed within 60 months of a previous paid claim with a diagnosis code of V81.0, V81.1, 0r V81.2 and a procedure code of 80061.
Description
Lipoproteins are a class of heterogeneous particles of varying sizes and densities containing lipid and protein. These lipoproteins include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and E apoproteins. Total cholesterol comprises all the cholesterol found in various lipoproteins.
Factors that affect blood cholesterol levels include age, sex, body weight, diet, alcohol and tobacco use, exercise, genetic factors, family history, medications, menopausal status, the use of hormone replacement therapy, and chronic disorders such as hypothyroidism, obstructive liver disease, pancreatic disease (including diabetes), and kidney disease.
In many individuals, an elevated blood cholesterol level constitutes an increased risk of developing coronary artery disease. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoprotein cholesterol (LDL -C) and high density lipoprotein cholesterol (HDL-C) are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases. Blood levels of the above cholesterol components including triglyceride have been separated into desirable, borderline and high-risk categories by the National Heart, Lung, and Blood Institute in their report in 1993. These categories form a
useful basis for evaluation and treatment of patients with hyperlipidemia. Therapy to reduce these risk parameters includes diet, exercise and medication, and fat weight loss, which is particularly powerful when combined with diet and exercise.
HCPCS Codes (Alphanumeric, CPT? AMA)
Code Description
80061 Lipid panel
Organ or Disease Oriented Panels (80048–80076)
Report organ or disease–oriented panel codes only when each panel component in the panel definition is performed. The assignment of organ or disease oriented panel codes is optional for most non–Medicare payers. You may assign an organ or disease panel code or opt to report each individual assay code. Medicare guidelines states that if all tests of a CPT defined panel are performed, the provider may bill the panel code or the individual component test codes. The panel codes may be used when the tests are ordered as that panel or if the individual component tests of a panel are ordered separately.For example, if the individually ordered tests are cholesterol (CPT code 82465), triglycerides (CPT code 84478), and HDL cholesterol (CPT code 83718), the service could be billed as a lipid panel (CPT code 80061).
80061 Lipid panel
A lipid panel includes the following tests: total serum cholesterol (82465), high–density cholesterol (HDL cholesterol) by direct measurement (83718), and triglycerides (84478). Blood specimen is obtained by venipuncture. See specific codes for additional information about the listed tests.
Coding Tip
This test may be performed using a CLIA-waived test system. Laboratories with a CLIA-waived certificate must report this code with modifier QW CLIA waived
test. See appendix 1 for CLIA-waived kits and test systems. Medicare covers colorectal screening for
* Indicates a mutually exclusive edit
80061 80500-80502, 82465, 83718, 83721, 84478
Laboratory Panels
Individual laboratory codes, which together make up a laboratory Panel Code, will be combined into and reimbursed as the more comprehensive laboratory Panel Code as described under the specific laboratory panel headings below.
Organ or Disease-Oriented Laboratory Panel Codes
The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076, and 80081. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters. UnitedHealthcare uses CPT coding guidelines to define the components of each panel.
UnitedHealthcare also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional. The Professional Edition of the CPT ® book, Organ or Disease-Oriented Panel section states: “Do not report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes.”
For reimbursement purposes, UnitedHealthcare differs from the CPT book’s inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare will bundle the individual Component Codes into the more comprehensive Panel Code when the combined reimbursement for the individual Panel Code(s)
exceeds the reimbursement amount of the Panel Code or when the designated number of Component Codes identified within a Panel Code are submitted as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076 and 80081 identify the Component Codes that UnitedHealthcare will rebundle into the specific panel.
Panel, 80061
A submission that includes all of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as a Panel CPT code 80061.
Panel Code: 80061
Includes all of the following Component Codes for the same patient on the same date of service:
82465 83718 84478
Two prevention and screening measures for the Centers for Medicare & Medicaid Services (CMS) Star ratings system and the Healthcare Effectiveness Data and Information Set (HEDIS®) are comprehensive diabetic care – cholesterol screening and comprehensive diabetic care – cholesterol level controlled. They measure the percentage of members 18 to 75 years of age with diabetes (type 1 and type 2) who have had their cholesterol level checked and have had their cholesterol level controlled. Below are the Current Procedural Terminology (CPT®), Current Procedural Technology Category II (CPT® II) and Logical Observation Identifiers Names and Codes (LOINC®) codes that indicate the LDL test has been performed and whether or not the LDL level is controlled. LDL controlled is defined as less than 100 mg/dL
Purpose of Policy
This policy is intended to help clarify how and why the same test or service may process differently depending upon the primary diagnosis code with which it is billed. The focus of this policy is on the differences between the Preventive and the Medical benefit categories.
Scope
This policy applies to all Commercial medical plans.
Reimbursement Guidelines
A. Categories of diagnostic tests covered and not covered as routine/preventive
1. Moda Health covers the preventive services mandated in the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.
2. In addition to the mandated PPACA preventive services, Moda Health also covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code.
The codes and tests eligible for this additional screening coverage are determined by a Moda Health Medical Director and are listed below. NOTE: These tests are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit because they are not on the PPACA list of mandated preventive services.
The tests will be covered (rather than denied), but all of the following tests are subject to the member’s usual cost-sharing and deductible requirements, even
when billed with a preventive diagnosis.
For another view of this concept, see also the summary table shown under #4 below.
The following additional CPT codes will be covered as noted above when submitted with a routine/preventive/screening diagnosis as primary on the line item:
• 80048 (Basic metabolic panel)
• 80050 (General health panel)
• 80051(Electrolyte panel)
• 80053 (Comprehensive metabolic panel)
• 80061 (Lipid panel)
• 81001 (Urinalysis, by dip stick or tablet reagent; automated, with microscopy)
• 82310 (Calcium; total)
• 83036 (Hemoglobin; glycosylated (A1C))
• 83655 (Lead)
• 84443 (Thyroid stimulating hormone (TSH))
• 85025 (Blood count; complete (CBC), automated)
• Chlamydia screening for males (87110, 87270, 87370, 87490, 87491, 87492, 87810)
(Note: female Chlamydia screening covered under PPACA @ 100%)
• Gonorrhea (gonorrhoeae) screening for males (87590, 87591 and 87592)
(Note: female Gonorrhea (gonorrhoeae) screening covered under PPACA @ 100%)
Q: Why am I getting denials of CPT code 80061?
A: Claims for lipid testing using 80061 will deny for not meeting medical necessity when not billed with approved diagnosis code from NCD 190.23
For a helpful reference listing of approved codes for this and other NCDs, see Lab NCDs –ICD10 spreadsheet
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